American healthcare has received heavy criticism in recent decades due to its cost/outcome profile. The sources of poor performance in the United States are many, to be sure, and yet one source rarely gets mentioned, namely, primary care.
Anyone following healthcare trends in the United States over the past decade will find few critiques of the deficiencies of primary care. In fact, the press clippings for primary care highlight the positive: a desire for more primary care providers (PCPs); a call for more coordination of care by PCPs; and the development of supportive structures around PCPs called “medical homes” and “accountable care organizations.”
One would assume that primary care is working well and that we just need to expand it in various ways. Yet, there is a body of information, both vast and well-known, if not well understood, that would suggest otherwise. Why then is everyone eager for more of the same?
The first answer to this question is that there is nothing wrong with primary care practitioners. They work hard, for less money than other medical specialists, and help their patients in many ways. To be clear, PCPs are not the problem with primary care.
Instead, primary care is underfunded and is not structured with the right players and the right practice leaders. Another way of saying this is that the problem lies within the primary care setting, and I will argue that current proposals for medical homes and accountable care organizations will not fix this clinical delivery dysfunction. I will propose an alternative structure that delivers better care.
We know that 70 percent of primary care visits stem from psychosocial issues1. Are PCPs equipped to understand and effectively address these issues? In general, PCPs have not been selected for clinical practice due to their temperament or desire to deal with psychosocial issues, and they receive very limited training to do so. It can be said then, with some exceptions, that they are not equipped to be effective in this regard.
What about the lifestyle issues and health behaviors that drive over 50 percent of our health status? How are PCPs at helping people with their diet, exercise, stress, sleep, social isolation, and feelings of loneliness, all of which are significant health risk factors? Again, it can be said that PCPs are not effective, and yet, to be fair, no one has a formula for success, not even behavioral health professionals.
While these facts should lead us to question the adequacy of the primary care model today, it appears fully ripe for dismantling when we recognize that behavioral health disorders are the number one source of disability today. Depression leads this group by far, with anxiety and substance use disorders contributing significant impairment. This is not just a U.S. phenomenon – the World Health Organization notes that depression is the leading cause of disability worldwide. In terms of healthcare costs in the United States, people with depression and anxiety have costs that are 70 percent higher than those without a mental health diagnosis, and people with depression are four times more likely to have a heart attack.
There are numerous troublesome facts like these, but even more worrisome is the reality that 80 percent of the people with behavioral health conditions get no treatment for these disorders. When PCPs identify them for treatment, they typically only get psychotropic medications, even though psychotherapy is remarkable effective and produces no side effects2.
While these facts challenge the rationale for the primary care model, they would be mitigated somewhat if we could point to a primary care workforce that is deeply satisfied, growing in numbers, and eager to meet these clinical challenges. The unfortunate reality is that a shortage of PCPs is projected for the future – by conservative estimates, 45,000 too few by 2020 – and physicians generally view primary care as less desirable than other specialties due to lower income and increased time demand. Choose your image, either the elephant in the room or the emperor with no clothes, but how can we not simply state that the primary care model is irreparably broken and in need of replacement?
Let’s start with a key element of the medical home model, namely, team-based care, and then let us reorient the model by replacing the primary care physician with a behavioral health specialist as the team leader. In so doing, we might excel at: detecting the psychosocial issues that are motivating office visits; addressing strategies for changing critical health behaviors; and finally, diagnosing and treating unrecognized conditions like depression, anxiety and substance use disorder. These issues require a team rather than a single behavioral health clinician.
We still need nurse practitioners to be on the front line for treating infections and injuries – more or less, the acute conditions – and we need PCPs to be the senior physicians addressing the chronic medical conditions that drive more than half of medical costs. Coordination of care must occur not just among the members of the primary care team, but across all the medical specialties that impact a given patient.